How to manage an adolescent female with major depressive disorder (MDD) on sertraline (Zoloft) who presents to the emergency room (ER) with a first episode of seizure and continues to have seizure episodes despite initial treatment with diazepam (Valium) and phenytoin (Dilantin)?

Management of Refractory Status Epilepticus in an Adolescent on Sertraline

This patient requires immediate escalation to third-line anesthetic agents for refractory status epilepticus, with midazolam infusion as the preferred initial choice, while simultaneously evaluating for sertraline-induced seizures and considering discontinuation of the SSRI. 1

Immediate Third-Line Treatment (Refractory Status Epilepticus)

Since this patient has failed both benzodiazepines (diazepam) and phenytoin, she meets criteria for refractory status epilepticus and requires anesthetic agents 1:

Midazolam infusion (preferred first choice for refractory SE):

• Loading dose: 0.15-0.20 mg/kg IV 1
• Continuous infusion: 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1
• Success rate: 80% 1
• Hypotension risk: 30% (lower than pentobarbital at 77%) 1
• Requires continuous EEG monitoring to guide titration 1

Alternative anesthetic agents if midazolam fails:

• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion; 73% efficacy but requires mechanical ventilation; causes hypotension in 42% 1
• Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion; highest efficacy at 92% but 77% hypotension risk and longer ventilation time (14 days vs 4 days with propofol) 1

Critical Concurrent Actions

Load a long-acting anticonvulsant during midazolam infusion to prevent seizure recurrence when tapering anesthetics 1:

• Valproate 30 mg/kg IV over 5-20 minutes (preferred: 88% efficacy, 0% hypotension risk) 1, 2
• Levetiracetam 30 mg/kg IV over 5 minutes (68-73% efficacy, minimal cardiovascular effects) 1
• Avoid additional phenytoin loading since she already received it 3

Initiate continuous EEG monitoring immediately as transition to non-convulsive status epilepticus is common, and clinical cessation of motor activity does not guarantee electrical seizure termination 1, 4

Sertraline-Specific Considerations

Evaluate sertraline as a potential seizure trigger 5:

• Sertraline FDA labeling lists seizures/convulsions as a serious side effect 5
• SSRIs can lower seizure threshold, particularly in first episodes 5
• Strongly consider discontinuing sertraline given this is her first seizure and temporal relationship to SSRI use 5
• Do NOT abruptly stop without taper once seizures controlled (risk of discontinuation syndrome) 5

Rule out serotonin syndrome as a contributing factor 5:

• Check for: hyperthermia, autonomic instability, neuromuscular symptoms (rigidity, myoclonus, hyperreflexia) 5
• Serotonin syndrome can present with seizures as part of the syndrome 5
• If suspected, discontinue sertraline immediately and provide supportive care 5

Search for Reversible Causes

Simultaneously evaluate and correct treatable etiologies 1:

• Hypoglycemia: Check fingerstick glucose immediately and correct 1
• Hyponatremia: Particularly relevant as SSRIs can cause SIADH, especially in adolescents 1, 5
• Drug toxicity: Consider sertraline overdose or drug interactions 1
• CNS infection: Meningitis/encephalitis workup if febrile or altered mental status 1
• Intracerebral hemorrhage or stroke: Neuroimaging once stabilized 1

Critical Monitoring Requirements

Continuous monitoring during anesthetic infusion 1:

• Continuous EEG to confirm electrical seizure cessation and guide medication titration 1
• Continuous cardiac monitoring and blood pressure (hypotension common with all anesthetic agents) 1
• Prepare for endotracheal intubation and mechanical ventilation (required for propofol, likely needed for high-dose midazolam) 1
• Monitor for respiratory depression 1

Critical Pitfalls to Avoid

Do NOT use neuromuscular blockers alone (e.g., rocuronium) as they only mask motor manifestations while allowing continued electrical seizure activity and ongoing brain injury 1

Do NOT delay escalation to anesthetic agents once benzodiazepines and second-line agent have failed—time is brain, and prolonged seizures increase risk of permanent neuronal injury 6, 7

Do NOT assume seizures have stopped based on cessation of motor activity alone—EEG confirmation is mandatory as non-convulsive status epilepticus is common after apparent clinical control 1, 4

Disposition and Follow-Up

ICU admission is mandatory for refractory status epilepticus requiring anesthetic agents 1

Continue EEG monitoring for at least 24 hours after apparent seizure control, as recurrence is common 4

Psychiatric consultation regarding sertraline continuation versus alternative antidepressant with lower seizure risk once medically stable 5